OPINION OF TRUSTEES
Respondent: Employer (Insurance Carrier)
ROD Case No: 58, January 16, 1980
Board of Trustees: Harrison Combs, Sr., Chairman; John J. O’Connell, Trustee; Paul R. Dean, Trustee.
Pursuant to Article IX of the United Mine Workers of America 1950 Benefit Plan and Trust, and under the authority of an exemption granted by the United States Department of Labor, the Trustees have reviewed the facts and circumstances of this dispute concerning coverage for treatment for mental illness for an Employee’s dependent and hereby render their opinion on the matter.
Complainant is an active mine worker eligible for health benefits under the Employer’s Plan. The Employee’s spouse was admitted to a hospital for medical reasons on March 26, 1978 for five days. The patient was transferred on March 30, 1978 to a second hospital for further diagnosis of and treatment for a psychiatric condition. Employee’s spouse remained hospitalized for 34 days (discharge: May 4, 1978). On May 10, 1978, the patient was readmitted to the same hospital for seven days of subsequent treatment of her condition (discharge: May 17, 1978). The attending psychiatrist admitted the patient to a third hospital on June 10, 1978 for reevaluation and treatment of a recurrence of mental illness. The patient remained in this hospital through August 18, 1978 (70 days). The Insurance Carrier denied payment for the last 21 days of the patient’s confinement in the third hospital.
Question or Dispute
The Employee has requested that coverage be provided for the entire length of the inpatient hospital confinement. The Insurance Carrier states that in accordance with the Employer’s benefit plan, ninety days of coverage is provided for treatment of a mental illness within a two-year period. The Employee’s spouse had exceeded this limitation and benefits were denied accordingly. The Employer concurs with the Insurance Carrier’s Position.
Positions of the Parties
Claimant’s Position: The Insurance Company should provide benefits for the entire term of inpatient hospital confinement, including that portion which exceeds the ninety-day limitation.
Employer’s (Insurance Carrier) Position: The Insurance Carrier is to provide benefits for ninety days of inpatient hospital care received within a two year period for treatment of mental illness. Benefits are not provided for care received beyond the ninety day limitation.
o Article III, Section A(1)(e) of the Employer Plan, provides as follows:
Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. Subject to the approval by the Plan Administrator, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness.
o 1978 Contract Question and Answer #43, as approved by the Trustees on June 8, 1978, provides as follows:
Question: The inpatient hospital benefit for mental illness limits the number of covered hospital days for mental illness as follows:
“Benefits are provided for up to a maximum of 30 days for a Beneficiary who is confined for mental illness in a hospital by a licensed psychiatrist. Subject to the approval by the Trustees, hospitalization may be extended for a maximum of 30 additional days for confinements for an acute (short-term) mental illness, per episode of acute illness, (More than 3 months of care over a two-year period is deemed for purposes of this Plan to be a chronic (long-term) mental problem for which the Trustees will not provide inpatient hospital benefits.)”
Does the limit of 3 months within a two-year period refer to hospitalization regardless of diagnosis, or does it refer to 3 months for the same diagnosis?
Answer: The limit refers to cumulative days of inpatient hospital care for all mental illness diagnoses, without regard to individual (acute) diagnosis, for up to 3 months (within a 2-year period).
The governing provision of the Plan provides only 90 days of care for treatment of a mental illness received within a two year period. In addition, 1978 Contract Question and Answer #43 clarifies that the ninety day limit refers to the cumulative number of days of inpatient hospital care for a mental illness diagnosis within a two year period. In this case, the Insurance Carrier made payment for 5 days of care to the first hospital for treatment of a medical problem. Benefits were then provided for 41 days of inpatient hospital care for mental illness to the second hospital. The Insurance Carrier later paid charges for 49 days of inpatient hospital care to the third hospital. At that point, the patient had exhausted the ninety day limitation on inpatient hospital care for mental illness provided in the Employer’s Plan.
Opinion of the Trustees
The Trustees are of the opinion that the Insurance Carrier is not responsible for provision of benefits beyond the ninety day limitation for the treatment of mental Illness received within a two-year period.